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A Co-Induction Technique Utilizing 4% Sevoflurane Followed by 0.75 medicina Article A Co-Induction Technique Utilizing 4% Sevoflurane Followed by 0.75 mg/kg Propofol in Elderly Patients Undergoing Minimally Invasive Procedures: A Prospective Randomized Control Study Omar A. Ababneh 1,* , Aiman M. Suleiman 2 , Isam K. Bsisu 1,* , Subhi M. Al-Ghanem 1, Walid K. Samarah 1, Khaled R. Al-Zaben 1, Ibraheem Y. Qudaisat 1, Lubna A. Khreesha 3 , Ghazi M. Al Edwan 4 and Mujalli M. Murshidi 4 1 Department of Anesthesia and Intensive Care, School of Medicine, The University of Jordan, Amman 11942, Jordan; [email protected] (S.M.A.-G.); [email protected] (W.K.S.); [email protected] (K.R.A.-Z.); [email protected] (I.Y.Q.) 2 Anesthesia and Intensive Care Department, Alabdali Clemenceau Hospital, Amman 11190, Jordan; [email protected] 3 Department of Otolaryngology, School of Medicine, The University of Jordan, Amman 11942, Jordan; [email protected] 4 Department of Urology, School of Medicine, The University of Jordan, Amman 11942, Jordan; [email protected] (G.M.A.E.); [email protected] (M.M.M.) * Correspondence: [email protected] (O.A.A.); [email protected] (I.K.B.); Tel.: +962-6-5353444 (O.A.A.); +962-6-5355000 (I.K.B.) Received: 17 November 2020; Accepted: 7 December 2020; Published: 10 December 2020 Abstract: Background and Objectives: Elderly patients constitute a large segment of healthcare receivers. Considering the functional deterioration of multiple organ systems with aging, achieving a safe perioperative approach is challenging. Our aim is to study the safety and effectiveness of a genuinely regimented co-induction technique in order to minimize anesthesia-related complications. Materials and Methods: One hundred and five patients were assigned to three groups according to the induction technique: propofol, sevoflurane and co-induction group. Inclusion criteria: patients with age 65 and American Society of Anesthesiologists physical status classification (ASA) II-III who ≥ 1 underwent endoscopic urological procedures. The propofol group received a dose of 1.5 mg kg− of propofol over two minutes for induction. The sevoflurane group received 8% of sevoflurane and 1 100% oxygen through a plastic facemask with the fresh gas flow set at 8 L min− . The co-induction 1 group received 4% sevoflurane through plastic facemask for two minutes, followed by a 0.75 mg kg− dose of propofol. After ensuring full range jaw relaxation, the laryngeal mask airway (LMA) was inserted. Results: Overall, the co-induction technique had a favorable profile in terms of respiratory adverse events, while the sevoflurane group had a favorable profile in terms of hemodynamic stability. Furthermore, 24 (68.6%) patients receiving inhalational sevoflurane had episodes of transient apnea, which constitutes 77.4% of the 31 episodes of transient apnea in the studied sample (p < 0.001). Moreover, six (17.1%) patients in the sevoflurane group had an episode of partial laryngospasm (p = 0.034). Compared with the co-induction group, we found that the propofol group had significantly less systolic and diastolic blood pressures in the second minute, with p values of (0.018) and (0.015), 1 respectively. Conclusions: The co-induction technique utilizing 4% sevoflurane at 8 L min− flow of 1 oxygen inhaled over two minutes followed by 0.75 mg kg− of propofol achieved less respiratory adverse events compared with the sevoflurane group, and less hemodynamic instability compared with the propofol group. Medicina 2020, 56, 682; doi:10.3390/medicina56120682 www.mdpi.com/journal/medicina Medicina 2020, 56, 682 2 of 14 Keywords: sevoflurane; propofol; co-induction; geriatric anesthesia 1. Introduction The co-induction technique refers to the employment of a combination of drugs to achieve a greater effect than each drug alone [1]. It is an approach that can greatly benefit elderly patients and patients with chronic diseases involving major organs in whom anesthesia could confer a greater risk if hemodynamics are altered. Many rationales stand behind the development of co-induction techniques. The most important one is the more balanced ratio of desired versus adverse effects [1]. When anesthetizing a patient, the anesthesiologist decides the proper induction technique based on several factors related to the patient and the planned procedure [2,3]. Propofol is a widely-used intravenous agent during induction and maintenance of general anesthesia [4–6]. Compared with other intravenous anesthetics, propofol provides optimal suppression of airway reflexes during laryngeal mask insertion with rapid onset of action and smooth recovery and has a relatively stable hemodynamic profile if dosed and administered properly [7–10]. However, its use is associated with some disadvantages such as bradycardia and hypotension on induction, depression of ventilation, and pain on injection [11–13]. Inhalational induction benefit to risk ratio has been studied extensively for non-pungent agents such as halothane and sevoflurane [14]. Considering its pharmacokinetic properties and absence of major side effects, sevoflurane represents a safe and reliable inhalational induction agent in various clinical settings [15]. Nevertheless, several adverse events were reported following its use such as postoperative nausea and vomiting [14]. Co-induction techniques employing inhalational and intravenous anesthetic agents consist of wide varieties and possibilities [16,17]. Elderly patients constitute a large segment of the general population receiving healthcare services worldwide. Taking into consideration the functional deterioration in several organ systems with aging, along with higher perioperative morbidity and mortality, this puts the anesthesiologist under the challenge of keeping the patient safe before, during, and after the surgery [18–20]. Hence, it is prudent to ask the question: how can we conduct anesthesia in a safe and efficient manner in these groups? As research on optimizing anesthetic approaches to these patients takes the lead, co-induction techniques should be investigated while taking recent proper anesthetic data and reviews into consideration. Our aim is to study the safety of a genuinely regimented co-induction technique in terms of efficiency of laryngeal mask airway (LMA) insertion, hemodynamic stability based on systolic blood pressure readings, and peri-induction adverse events, in order to minimize anesthesia-related complications. 2. Materials and Methods 2.1. Study Design This prospective randomized control study was conducted at Jordan University Hospital, a tertiary hospital in Amman, Jordan. The study design and technique were approved by the institutional review board (IRB) committee at Jordan University Hospital (reference number: 10/2016/4597 and the clinical trial number: NCT04284644). Clinical trial registration was completed retrospectively on 24 February 2020 [21]. Moreover, the study was reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement (http://www.consort-statement.org/). The structure of this study is a comparative analysis of three distinct approaches to induction, each approach utilizes one of the following techniques: propofol alone, sevoflurane alone, or co-induction technique employing both drugs. It enrolled 105 patients who were assigned by a computer-generated randomization via Research Randomizer (www.randomizer.org) to three groups of equal numbers according to the induction technique used: propofol group, sevoflurane group and co-induction group. All groups received 1 pre-oxygenation of three minutes duration at 8 L min− flow of oxygen. The propofol group received a Medicina 2020, 56, 682 3 of 14 1 dose of 1.5 mg kg− of propofol slowly over two minutes for induction. The sevoflurane group received 1 8% sevoflurane through sealed plastic facemask at 8 L min− flow of oxygen. The co-induction group 1 received 4% sevoflurane through sealed plastic facemask at 8 L min− flow of oxygen for two minutes, 1 followed by a dose of 0.75 mg kg− of propofol given slowly. After ensuring full range jaw relaxation, the laryngeal mask airway (LMA) was inserted. 2.2. Sampling Informed written consents were obtained from all enrolled patients. Our inclusion criteria included patients with age 65 and American Society of Anesthesiologists physical status classification ≥ (ASA) II-III who underwent minimally invasive endoscopic urological procedures, such as cystoscopy, ureteroscopy, double-J catheter insertion, and transurethral bladder resection. The exclusion criteria contained patient refusal to any of the techniques after operating room admission, family history of malignant hyperthermia, prolonged surgeries that needed intubation due to unexpected events 2 intraoperatively and body mass index (BMI) more than 35 kg m− . 2.3. Materials All patients were appropriately prepared by perioperative assessment, followed by 6 h fasting, during which they were kept on maintenance intravenous Ringer’s lactate solution. Patients did not receive any sedative drugs pre-operatively. In the operating room, patients in all groups were monitored according to American Society of Anesthesiologists (ASA) guidelines for minimally invasive procedures. Intravenous access with a 20 gauge cannula was established before induction. Preoxygenation for three 1 minutes under 8 L min− flow of oxygen was performed. Patients were asked to hold a sponge ball in 1 their dominant hands. Then, 1.5 mcg kg− of fentanyl was given intravenously. Two minutes following the fentanyl dose, every patient received the induction technique according to his
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